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1/25/2018 7:38:29 AM
Posted: 4/1/2006 6:06:40 PM EST
[Last Edit: 4/1/2006 6:08:17 PM EST by JBravo223]
Question about out-of-network coverage ! please read.

I am scheduled for surgery on 4/11/2006 at the hospital for special surgery in nyc. Everything is out of network including my surgeon.

I have guardian healthnet for insurance and my benifit break down is as follows:

copay information (the amounts and percentages are what I am responsible for)
office visit copay
in-network $5
out-of-network 20%

emergency room copay
in-network $50
out-of-network $50

urgent care center copay
in-network $50
out-of-network $50

specialist copay
in-network $5
out-of-network $50

rehabilitation therapy copay
in-network $5
out-of-network 20%

allergy copay
in-network $5
out-of-network 20%

mental health copay
in-network $5
out-of-network 20%

outpatient services copay
in-network $0
out-of-network 20%

hospital inpatient services copay
in-network $0
out-of-network 20%


my out of poket maximum is $1200 for out of network with a $200 deductible.

The policy defines out of poket maximum as

individual out of pocket maximum the maximum dollar amount generally includes coinsurance / deductibles and copayment for which the member is reponsible in a calendar year. Once satisfied, no additional copayments, coinsurance or deductibles will be required for the individual member for the remainder of the calendar year.

the policy defines hospital inpatient services copay as

hospital inpatient services copay inpatient services in a hospital are covered, subject to the scheduled copayments. Some plans, however, charge a flat dollar amount or percentage of the inpatient admission copayment. Benefits for hospital care are limited to the hospital�s most common charge for a semiprivate (two-bed) room. If the member elects to have a private room, the member is responsible for any amount over the semiprivate room rate, plus the copayment called for by the plan. If the participating provider group (ppg) or qualified physician has authorized a private room as medically necessary, the member has no financial responsibility beyond the required copayment.

i am prepared to pay the $1200 dollar max because I set up my flex plan for that. My real concern is having to pay anything above and beyond that. Is the out of pocket max the only thing I need to worry about? Can I get hit with more expenses?

Please give me your advice regarding the matter...


Link Posted: 4/1/2006 6:08:40 PM EST
Out-Of-Network = 'Bend-Over'
Link Posted: 4/1/2006 6:10:11 PM EST
The other hospital that he is affiliated with is in network" for me and I am not sure if he still operates there, if he does I am sure it would be at least a 2 month wait. This is for a spinal fusion...
Link Posted: 4/1/2006 8:23:26 PM EST
Make sure you are refered by an "in network" doctor and make sure you make this known to your insurance co. and get preapproved for the "out of network".
With some insurances if you do this it is treated as "in network".

Link Posted: 4/1/2006 8:53:32 PM EST
The problem is not so mcu going to be the deductible or the copays, which are bad enough. The big reaming is going to be when you ALSO for the difference between what the insurance company figures is an allowable fee and what the provider wants


Dr's charge $1,000
Insurance company's idea of what's an allowable fee: $350
Ins. pays 50% (out-of-network rather than in-network 80%) $175
You owe $1,000 - $175 = $825

Out of network = no contractual fee = just hand over your wallet to each one abne ask them if they will respect you in the morning.....

Today, a good doctor is not only a good clinician, but also good at working within the context of the patient's coverage and finances. Some others go out of their way to avoid networks for the very reason that they know exactly what it means financially to them. The good doc's don't do that. Sometimes the insurance companies do underpay the doctors, but there are many excellent Dr.s who have no problem whatsoever contracting with the insurance companies.
Link Posted: 4/1/2006 8:59:41 PM EST
I'm not sure if you will incur additional expenses, as the insurance industry seems to find ways to get the most out of people.

I would phone the insurance company, take notes and names, and ask specifically whst you will be expected to pay.

One other thing that you can try, is to negotiate your obligation with the hospital after the fact.

Often, the hospitals will inflate the charges for an insured patient, and the insurance company's 80% is MORE then they would have received from a cash patient. My insurance was billed $13,000.00 for a standard delivery, that would have cost $4000-$5000, had I been a cash patient. They received more from the insurance company, then I would have been asked to pay if I didn't have insurance at all.

After the insurance payment has been made, ask for an itemized accounting of the charges, and go through them line by line. There WILL be errors, they will be adjusted off of your percentage..or if you are a big enough pain in the ass, they will make an offer to settle.

In my case, a $2500+ co-pay, was negotiated down to $500.

Good luck with the upcoming surgery.
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